ORANGE COUNTY PUBLIC SCHOOLS SCHOOL ENROLLMENT INFORMATION

To register your student in school, the following documentation is necessary:

*The School Board of Orange County, Florida is authorized to collect social security numbers (“SSN”) of students as set forth in Sections 1008.386 and 119.071 (5)(a) 6, Florida Statutes. The provision of a student’s SSN on the enrollment form is optional and is not required as a condition for enrollment within the District.Any SSN provided in connection with enrollment will only be used for research, reporting and recording purposes. The collection of the SSN shall not be used for immigration enforcement. Providing the student’s SSN to the School Board of Orange County, Florida for these purposes means that you consent to the use of the student’s SSN in the manner described.

Verification of Legal Name • Birth Certificate

Verification of Age (with one of the following): • Birth Certificate• Passport

To enter Kindergarten, a child must be 5 years old on or before Sept. 1. To enter first grade, a child must be 6 years old on or before Sept. 1 and successfully completed Kindergarten.

Verification of Immunization and Physical Exam • Proof of immunizations on a Form 680, which can be obtained at the Orange County

Health Department; 832 W. Central Blvd., Orlando, Fl. Phone Number: 407-836-2600 • Proof of physical examination by a U.S. doctor within the last year. If documentation

cannot be provided a physical examination must be obtained within 30 days.

Verification of Academic History • Transcript• Withdrawal Form• Last report card

Verification of Special education information (if applicable) • Current IEP• Current 504 plan

Verification of your domicile in Orange County (with one of the following): • Current Homestead Exemption Card or a property tax statement• Signed Settlement Statement• Current lease (Additional documentation could be requested)• Verification of address: Documents required-information available on OCPS website.

Pupil Assignment - (407) 317-3233

Verification of Guardianship • Birth CertificateIf applicable, you must provide one of the following: • Court Custody Documentation (this includes divorce decrees)••

OCPS Educational Guardianship (given only when the parent/guardian lives outside of OrangeCounty or adjacent counties of Brevard, Osceola, Polk, Lake, Seminole and Volusia) available at:

Pupil Assignment is located at the Ronald Blocker Educational Leadership Center 445 W. Amelia St., Orlando, Fl. 32801

Temporary Documentation Exemption: Students who lack a fixed, regular and adequate nighttime residence, have a right to immediate enrollment under the McKinney-Vento Homeless Assistance Act 42 U.S.C. 11435. A completed Student Residency Questionnaire is needed to determine eligibility (page 8). For further assistance, please visit: www.homeless.ocps.net or call office: 407-317- 3485.

Schedule your appointment at http://pupil.ocps.net

ORANGE COUNTY PUBLIC SCHOOLS Orlando, Florida

Student Registration Form

Student Number: ______________________________ School: ____________________________________

Student Alias # ______________________________ Date: Grade: ________________

School Year 2014-2015 In Orange County public school before Yes No

STUDENT INFORMATION Last Name (Legal) Generation

(i.e.: JR, II) First Name (Legal) Middle Name Preferred Name * Student SSN #�(optional)������������������������

Domicile Address Apt # City Zip Code Primary Phone Number

Mailing Address City Zip Code Birth Date (Month/Day/Year)

Birth Weight (Lbs. and oz.)

Birthplace (City/State/Country)

Parent/Guardian - Primary E-mail Address

Gender Federal Ethnic Category Federal Race Categories (Check all applicable)

Do you need communication sent home in a language other than English?

Student Lives With

Male Female

Non-Hispanic/Non-Latino Hispanic/Latino

White Black or African American Asian American Indian/Alaska Native

Native Hawaiian or other Pacific Islanders

No Spanish Haitian Creole Yes French Vietnamese

Portuguese

Both Parents Parent & Step Parent Mother only Legal Guardian Father only Other

OTHER SCHOOL AGE CHILDREN LIVING AT HOME

Child’s Name (First & Last) Relation to Student School Gr. Child’s Name (First & Last) Relation to Student School Gr. 1. 2.

3. 4.

5. 6.

Domicile is defined as the place where parents/guardians have their true and fixed, permanent home and to which they have, whenever absent, the intention of returning. The parent/guardian's domicile determines the student's domicile. Common indicators of domicile are home ownership or in the absence of home ownership a residential lease. 837.06 False official statements.ðWhoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083. This is to certify that all the information on this registration form is true to the best of my knowledge and belief. I understand that inadequate information may result in delayed entry. Falsification of information will forfeit student's athletic and extracurricular eligibility for one (1) calendar year from the date of discovery of the violation.

______________________________________________________ Parent/Guardian Signature Date Relationship to Student

______________________________________________________

Parent/Guardian Signature Date Relationship to Student

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Student Name: __________________________________ Student Number: __________________________________

ADDITIONAL STUDENT INFORMATION: If the answer is"yes" to any of these question, the student will be tested for English Proficiency.

1. Home Language: Is a language other than English spoken at home?

No Yes What language? ___________________________________

3. Native Language:Did the student have a first language other than English?

No Yes What language? ___________________________________2. Dominant Language:

Does the student most frequently speak a language other than English? No Yes What language? ___________________________________

4. Born outside United States - If NO enter N/A

Date 1st entered U.S. school:

1. Identified as a special education student or has an active IEP ? No Yes 5. Has student ever been arrested, resulting in a charge? No Yes 2. Does student have a current 504? No Yes

3. Has student ever received a McKay scholarship? No Yes 6. Has student ever had Juvenile Justice action taken against him/her? No Yes

4. Has student ever been expelled from a previous School? No Yes If yes, Date: _____________ School (Name/County/State): ______________________________

7. Is student on Community Control? No Yes

8. Is the student a parent? No Yes

MILITARY FAMILY STUDENT SURVEY

No Yes Parent is an active duty member of the uniformed services, including members of the National Guard and Reserve on active-duty orders

No Yes Parent is a member or veteran of the uniformed services who is severely injured and medically discharged or retired for a period of 1 year after medical discharge or retirement

No Yes Parent died as an active duty member of the uniformed services or within one year of injury.

LAST THREE SCHOOLS ATTENDED (Begin with the most recent – For Kindergarten registration – please, list Pre-K)

Type of School Name of School City, State Years Attended Grade1. Public Home Education Private 2. Public Home Education Private 3. Public Home Education Private

1ST TIME KINDERGARTEN STUDENTS

Program Participation Prior to Kindergarten

(V) Voluntary Prekindergarten (VPK) at a Public School Name: _________________________________________________________

(P) Prekindergarten Provider (VPK) at Private School Provider Name: _________________________________________________________

(D) Prekindergarten Program (VE-PK) for children with Disabilities Name: _________________________________________________________

(H) Head Start Name: _________________________________ (N) None

DOMICILE INFORMATION Parent/Guardian is in Federal Military Services or is a civilian employee, the cost of whose child’s education is provided in part or wholly by federal subsidy to state-supported schools

Parent/Guardian has lived in Florida for the past year or longer

Parent/Guardian has purchased and occupies as his/her domicile a home in Florida

Parent/Guardian is a migratory agriculture worker

Parent/Guardian has a Verification of Residence

Parent/Guardian has a valid lease agreement - expiration date: ______________________

______________________________

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_______________________________________________________

ORANGE COUNTY PUBLIC SCHOOLS Orlando, Florida

Student Contact Information Student Name: Student Number: _____________________________ PARENT/GUARDIAN INFORMATION (Please list parent/guardian in order of contact priority.)

Last Name (Legal) First Name (Legal) Middle Name Business Phone

Domicile Address Apt # City Zip Code Primary Phone Number Cell Phone

Parent/Guardian - Primary E-mail Address Pickup student?

Parent/Guardian Relation to Student

Parent Guardian Other/Relative

Guardian Ad Litem Surrogate Parent

Mother Father Legal Guardian

Stepmother Stepfather Grandmother

Grandfather Brother Sister

Aunt Uncle Cousin

Neighbor Other

Last Name (Legal) First Name (Legal) Middle Name

Domicile Address Apt # City Zip Code Cell Phone

Primary E-mail Address Pickup student? Legal Documentation(example: custody, restraining order, etc.)If there is no Legal Alert: Enter "N/A" Please provide supporting documentation

Parent/Guardian Relation to Student

Parent Guardian Other/Relative

Guardian Ad Litem Surrogate Parent

Mother Father Legal Guardian

Stepmother Stepfather Grandmother

Grandfather Brother Sister

Aunt Uncle Cousin

Neighbor Other

OTHER CONTACT - Relationship __________________________________ Last Name First Name Contact Phone Pickup student? Pickup student?

Yes No

837.06 False official statements.—Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.

This is to certify that all the information on this registration form is true to the best of my knowledge and belief. I understand that inadequate information may result in delayed entry.

Falsification of information will forfeit student's athletic and extracurricular eligibility for one (1) calendar year from the date of discovery of the violation.

Parent/Guardian Signature Date Relationship to student

Parent/Guardian Signature Date Relationship to student4

Yes No

Yes No

______________________________________________________

______________________________________________________

Work Phone

Business Phone Work Phone

Home Phone

Legal Documentation (example: custody, restraining order, etc.) If there is no Legal Alert: Enter "N/A" Please provide supporting documentation

Emergency Information - English

Student Number: ____________________STUDENT INFORMATION

PHYSICIAN INFORMATION Doctor’s Name Dentist’s Name Preferred Hospital

Doctor’s Phone Number Dentist’s Phone Number Currently Under Physician’s Care No Yes

Insurance Insurance Phone Number Policy # Group #

Medicine Currently Taking

Medical History

Allergies

PARENT/GUARDIAN INFORMATION (Please list parent/guardian in order of contact priority.) Last Name First Name Relationship Pick up

Yes No

Domicile Address Apt # City Zip Code

Home Phone Cell Phone Employer Business Phone

Last Name First Name Relationship Pick up

Yes No

Domicile Address Apt # City Zip Code

Home Phone Cell Phone Employer Business Phone

ADDITIONAL CONTACTS ON THE NEXT PAGE **Proof of address must be presented to the school Registration Office in order for the address to be officially changed in the system.

Last Name (Legal) Generation (i.e. Jr., II)

First Name (Legal) Middle Name (Legal)

Preferred Name Legal Documentation (example: custody, restraining order, etc.) If there is no Legal Alert: Enter "N/A" Please provide supporting documentation

Gender Birth Date Primary Phone Male Female

Primary E-mail

Address Domicile

Address**

Apt # City Zip Code

Mailing Address Apt # City Zip Code

Do you need communication in a language other than English?

No Yes Spanish French Portuguese Haitian Creole Vietnamese

ORANGE COUNTY PUBLIC SCHOOLS Orlando, Florida

Emergency Student Information Form School Year 2014-2015

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Student Name: Student Number:

ADDITIONAL CONTACTS Last Name First Name Relationship Contact Phone Custody Pick up

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

SCHOOL HEALTH SERVICES I hereby give my consent for this child to participate in the School Health Services Program. My child will receive emergency care in school, and health appraisals including vision, hearing, growth and development. If, upon administering a vision screening through the school or any other OCPS program, my child is determined to have a need for a follow-up vision examination and if my child is eligible or otherwise financially qualified, I hereby authorize for OCPS or a designated third party to provide any necessary follow-up vision care, including any subsequent examination and corrective lenses, as needed. In the event of a serious accident or illness and I cannot be reached, I hereby authorize the school to contact the physician or dentist and for those professionals to provide protected health information.In the event of an EMERGENCY, I understand that the school will access the 911 emergency medical system immediately. To expedite care I give my permission for school personnel to provide medical information to the responding emergency team to initiate treatment, and transport to an appropriate facility. I give my permission for the appropriate medical personnel and staff to initiate treatment immediately upon arrival to the appropriate facility. I request to be notified of my childôs condition and admission as soon as possible. If I cannot be reached, I request that the

admitting facility notify one of the other persons listed above of my child’s condition and admission. I agree to be financially responsible for my child’s total treatment, and transport.

I have reviewed the above information and have made corrections as needed.

Call Doctor Call Ambulance Treat

(This form is effective for one year from the date signed)

Securitysy

Parent/Guardian: Date:

I authorize the School District of Orange County, Florida to release and exchange my childôs confidential information to agencies of the State of Florida which would allow Orange County Public Schools to verify Medicaid eligibility, bill Medicaid for reimbursable Certified School Match services referenced on my childôs IEP and receive Medicaid reimbursement for Exceptional Student Education (ESE) services it provides to my child while at school. I understand that my child will continue to receive services referenced on his/her IEP whether or not I give consent. Please take the student's Social

Security card to the school Registrar to finalize authorization.

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Permission to:

*The School Board of Orange County, Florida is authorized to collect social security numbers (“SSN”) of students as set forth in Sections 1008.386 and 119.071 (5)(a) 6, Florida Statutes.The provision of a student’s SSN on the enrollment form is optional and is not required as a condition for enrollment within the District.Any SSN provided in connection with enrollment will only be used for research, reporting and recording purposes. The collection of the SSN shall not be used for immigration enforcement. Providing the student’s SSN to the School Board of Orange County, Florida for these purposes means that you consent to the use of the student’s SSN in the manner described.

PUBLIC NOTICE OF PARENT RIGHTS STUDENT RECORDS

ORANGE COUNTY PUBLIC SCHOOLS

PARENT RIGHTS: STUDENT RECORDS

As a parent, The Family Educational Rights and Privacy Act (FERPA) affords you certain rights with respect to your student's education records. These rights are:

1. The right to inspect and review the student's education records within 45 days of the day the school receives a request for access. You must submit a written request to the principal that identifies the record(s) you wish to inspect. The principal will make arrangements for access and notify you of the time and place where the records may be inspected.

2. The right to request the amendment of the student's educ ation record that you believe is inaccurate or misleading. You must write the principal, clearly identify the part of the record you want changed, and specify why it is inaccurate or misleading. If the school decides not to amend the record as requested, the school will notify you of the decision and advise you of your right to a hearing regarding the request for amendment.

3. The right toconsent t o disclosure of pe rsonally identifiable information contained in the student's education records, except to the extent that FERPA authorizes disclosure without consent. One exception, which permits disclosure without consent, is disclosure to school officials with legitimate educational interests. A school official is a person employed by the district as an administrator, supervisor, instructor, or support staff; the person elected to the school board; or, a person or company with whom the district has contracted to perform a specific task. A school official has a legitimate educational interest if the official needs to review an education record in order to fulfill his or her professional responsibility. Personally identifiable information will be releasedwithout consent to appropriate officials in emergency situations, to comply with a lawfully issued subpoena and in cases involving compulsory school attendance and child abuse.

4. The right to file a complaint with the U.S. Department of Education concerning alleged failures by the school to comply with the requirements of FERPA. The address of the Office that administers FERPA is:Family Policy Compliance Office, U.S. Department of Education, 400 Maryland Avenue, SW, Washington, DC 20202-4605.

RELEASE OF DIRECTORY INFORMATION

Orange County Public Schools may release the following ”directory information” without your permission unless you notify the principal, in writing, within ten (10) calendar days of the receipt of this public notice. Directory Information: Student’s name, address, grade level (if junior or senior), dates of attendance, participation in school sponsored activities and sports, weight and height of members of athletic teams, and awards and honors received. (Military recruiters may also obtain telephone numbers of high school students.)

Under the provisions of the Family Educational Rights and Privacy Act, you have the right to withhold the release of the directory information listed above. If you decide that you do not want the school to release the information listed above, any f uture requests f or the "directory information” f rom individuals, organizations or other entities not affiliated with the school or district will be refused. Please indicate here your request to withhold the items listed above.

I do not want my child’s directory information released as described above.

Parent Name: ___________________________ Parent Signature:

Student Name: ___________________________ Grade: _________ Date:

If the form is not received by the school principal within ten (10) calendar days, it will be assumed that the above information may be released for the remainder of the school year.

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Natural Disaster Type:_________________ Other___________

___ Foreclosure No

The answers to this residency questionnaire help in determining eligibility of services that may be received through the federal

McKinney-Vento Homeless Assistance Act 42 U.S.C. 11435. The OCPS MVP office: 407-317- 3485; www.homeless.ocps.net

School _________________________ Date_________________________

1. Where are you and your family currently staying? Check one box.

Rent/own my own home.

Living with someone by choice, whereas housing is fixed, regular and adequate.

If you rent/own your own home, or live with someone by choice, STOP and sign below (under Number 4).

In an emergency/transitional shelter (A)

Temporarily with another family due to loss of housing, economic hardship, or similar reason (B)

In a vehicle of any kind, trailer park or campground, abandoned building or other substandard housing (D)

In a hotel/motel due to loss of housing, economic hardship, or similar reason (E)

Awaiting foster care placement (F)

Please explain where the student is presently living, if the above situations do not apply. Other: _________________

Cause of temporary residence:

Are you alone without an adult or with an adult that is not a parent or legal guardian? (U)

2. Student information, including all school-aged siblings living together in the above living situation.

Student’s Name Student ID # M/F D.O.B Grade School

Please list all children under school age (0-5 yrs. old)

3. Additional protective rights and services may be available, such as:

Immediate enrollment into school

School stability – continue in the school attended

before loss of housing or last school attended, if

feasible and in the student’s best interest

Referral Services

Phone: 2-1-1; Community Service Directory

4. The undersigned certifies that the information provided is accurate.

___________________________________________________ ________________________________________ PRINT - Parent/Guardian or Adult caring for Student/Unaccompanied Youth SIGNATURE

__________________________________________________________________________________________________ STREET ADDRESS CITY STATE ZIP PHONE

Florida Statutes 837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public

servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree.

OCPS DISTRIBUTION

If it is determined that this student is eligible for McKinney-Vento Program services, copies go to:

1. MVP Liaisons; Fax 407-317-3332 2. School Food Service Manager * 3. School-based McKinney-Vento Coordinator

* Please preapprove for 10 days and keep copy on file

Foreclosure

Yes

2014-2015 Student Residency Questionnaire

Transportation - to remain at the “school

of origin”, if over 2 miles

Free Meals

ORANGE COUNTY PUBLIC SCHOOLS Authorization for Release of Information

School Year 2014-2015

Date: Student Number: ___________________________

To Whom It May Concern:

The following student has enrolled at our school. Please send all records including grades, courses taken, test scores, special education, psychological data, current individualized education plan (IEP), health records and immunization dates. Also, please include all grades earned this school year and/or withdrawal grades, if any.

Identifying Information Student’s Name

____________ ________________ _______________ First Middle Last

Date of Birth

________________

Parent(s)/Guardian(s) Name

_____________________________________________________

Phone #

________________

Name of Last School Attended

________________________________________________________________________________

Complete Mailing Address of Last School Attended

_________________ ______________ ______ ________ Street City State Zip

____________________________ ________________________ Phone# Fax#

Send Requested Records To `

Parent/Guardian Signature Date:

Principal or Records Clerk

Prior written consent of the parent or guardian of the student is not required to transfer records to schools in which the pupil or student seeks or intends to enroll.

1st request 2nd request 3rd request

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